Contraception

Question 1

What are the advantages of contraception?

Answer 1

Choice/control for personal/medical reasons
Pregnancy spacing (health)
Cost sometimes
Saves lives globally

Question 2

What are the disadvantages of contraception?

Answer 2

Changes in sexual habits
Increased promiscuity
Medical complications
Cost sometimes

Question 3

What must be considered in a contraceptive consultation?

Answer 3

Health
Age
Desire for fertility
Social/religious/ethical
Education
Compliance
Cost

Question 4

What are the 4 different types of contraceptive methods from least to most reliable?

Answer 4

1. Natural/physiological
2. Barrier
3. Hormonal
4. Surgical

Question 5

What natural/physiological contraceptive methods exist?

Answer 5

1. Calendar rhythm method: prevent sperm/egg interaction
2. Coitus interruptus: prevent sperm/egg interaction
3. Lactation: prevents ovulation but only with exclusive regular feeding

Question 6

What is the mechanism of action of the calendar rhythm method?

Answer 6

In rhythm with woman’s natural fertility as the ovum has a limited period of fertilised so intercourse should be avoided in fertility window, 4-5 days prior and 1-2 days after predicted ovulation

Question 7

When does ovulation normally take place? What is a tell-tale sign?

Answer 7

~ day 14

Spinbarkeit (spinnability) of vaginal mucus or higher body temperature

Question 8

What are the advantages and disadvantages for the calendar rhythm method and coitus interruptus?

Answer 8

Adv: cheap/no side effects, no medical contraindication and no religious/ethical problems

Disadv: limits sexual activity, education (3-6mths), failure rate higher and no STI protection

Question 9

What is the mechanism of action of lactation?

Answer 9

Regular and exclusive (i.e. no bottle feeds) breastfeeding for ~6 months will induce production of prolactin which inhibits secretion of FSH, suppressing HPO axis so no ovulation takes place but failure rate is an issue

Question 10

What is coitus interruptus?

Answer 10

Penile withdrawal before ejaculation

Question 11

What 4 barrier contraceptive methods exist?

Answer 11

1. Condom
2. Diaphragm
3. Cervical cap
4. Plus - spermicide

Question 12

What is the main mechanism of action of barrier contraceptive methods?

Answer 12

Prevent sperm/egg interaction

Question 13

How does the diaphragm and cap work?

Answer 13

Inserted in the vagina with spermicide in it just before sex, left in for 6 hours after sex and then can be taken out so patients need to be educated on its use

Question 14

What are the advantages and disadvantages of condoms?

Answer 14

Adv: cheap/readily available and STI protection

Disadv: latex allergy, some sensation loss/interruption/accidents, education (beware of body oil and Vaseline w/ latex) and female condom even less popular

Question 15

What is the mechanism of action of long acting reversible contraception (LARC)?

Answer 15

Copper IUD releases copper which is a spermicide and mechanically prevents implantation

Question 16

What are the advantages of long acting reversible contraception (LARC)?

Answer 16

Long-term
Doesn't limit/interrupt sexual activity
IUCD copper has no artificial hormones
Amenorrhea
Decreased dysmenorrhea
Partner unaware (sometimes string can be felt in IUCD)

Question 17

What are the disadvantages of long acting reversible contraception (LARC)?

Answer 17

Decreased libido
Irregular bleeding
Amenorrhea may be beneficial
Cost
Invasive
No STI protection

Question 18

When should the intra-uterine contraceptive device (IUCD) be used?

Answer 18

Long-lasting for 1-12 years so good for women who are older/parous, if compliance is a problem and can be used as emergency contraception is implanted within 5 days of unprotected sex

Question 19

What are the complications of the intra-uterine contraceptive device (IUCD)?

Answer 19

Expulsion
Perforation
Infection (PID) as string provides a route up to uterus
Ectopic

Question 20

What are the side effects of the cooper/inert intra-uterine contraceptive device (IUCD)?

Answer 20

Bleeding
Cramping
Usually good or bad

Question 21

What is a termination (TOP)?

Answer 21

Often called an abortion - legal to 24/40 weeks gestation in UK which can be:

1. Medical (up to 9/40): Mifepristone/Misoprostol
2. Surgical: vacuum aspiration (15/40) or dilation and curettage (>15/40)

Question 22

What is surgical sterilisation?

Answer 22

Irreversible method of preventing sperm/egg interaction via surgical interruption:

• Male = vasectomy
• Female = tubal ligation

Question 23

What are the problems with surgical sterilisation?

Answer 23

Requires counselling
Costly
Invasive
Failures still exist

Question 24

What are oral hormonal contraceptives?

Answer 24

Synthetic steroid hormones that mimic the function of oestrogens and progesterone:

• Combined inc. oestrogen and progesterone
• Progesterone-only version

Question 25

What is the mechanism of action of oral hormonal contraceptives?

Answer 25

Act upon oestrogen and progesterone IC TFs by diffusing across cell membranes: - ER1⍺ and ERβ for oestrogen - PR-A and PR-B for progesterone Binding of hormone drives receptor activation via dissociation from HSP90 so active receptor dimers then form, move into nucleus and influence gene expression influencing tissue growth, regeneration and secretion of hormones

Question 26

What are the primary outcomes of oral contraceptives?

Answer 26

SUPPRESSION OF OVULATION: - Combined: must be taken at right time to disrupt critical endocrine events required for ovulation - Progesterone only: taken asynchronously and exerts additional effects that disrupt fertilization and implantation (makes body think you are already pregnant)

Question 27

What drives ovulation?

Answer 27

Endocrine dynamics and relative TIMING of hormone secretion and activity - LH surge essential for this

Question 28

What happens to the corpus luteum if implantation occurs or does not occur?

Answer 28

Progesterone is produced by the corpus luteum during the menstrual cycle and with +ve embryo implantation, it is sustained and progesterone levels remain high promoting pregnancy but if there is no embryo implantation, it disintegrates so progesterone levels fall contributing to menses and the cycle resumes

Question 29

What usually happens to progesterone levels throughout the menstrual cycle?

Answer 29

LOW in follicular phase HIGH in luteal phase

Question 30

What is the problem with progesterone-only contraceptive pills?

Answer 30

High doses are required to suppress ovulation which can cause sig. nausea and this is still not 100% effective whereas combined pill is >99.8% effective so the progesterone-only pill is only used for emergency contraception or in situations when oestrogen-derived complications/risks occur

Question 31

What are the effects of progesterone?`

Answer 31

1. Negative feedback to hypothalamus + anterior pit. to reduce FSH/LH synthesis inhibiting ovulation 2. Inhibits endometrial gland development making implantation less favourable as sufficient nutrients would not be available 3. Thickens cervical mucus so inhibits sperm motility

Question 32

What can progesterone intra-uterine systems (IUS) be used for?

Answer 32

E.G. Mirena can incorporate a progesterone-releasing polymer component that lasts up to 5 years which is a very effective contraceptive system BUT can also treatment conditions such as menorrhagia

Question 33

What are the common adverse effects of oral contraceptives?

Answer 33

Breakthrough bleeding Nausea Depression Increased risk of CVD complications with oestrogen-containing pills (e.g. thromboembolism, stroke, IHD, raised BP) Slight increase in breast cancer risk in long-term use

Question 34

What other benefits to contraceptives offer?

Answer 34

Relief of symptoms of endometriosis, dysmenorrhoea, menorrhagia and acne in women Progesterone reduces risk of endometrial cancer too